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Gastric and intestinal metaplasia in Barrett's patients: Role of mixed acid-biliary reflux
April 1998 CONCLUSION: 1. Pantoprazole and lansoprazole were efficient in grade II and III esophagitis healing and symptoms relief. Both treatments were well tolerated. 2. No statistical difference was shown between these two proton pump inhibitors. 3. Hospital and private practice results are similar. Funded by Byk France laboratories. G0455 GASTRIC AND INTESTINAL METAPLASIA IN BARRETr's PATIENTS: ROLE OF MIXED ACID-BILIARY REFLUX. P. Dusi0, E. Gay, U. Giacobbe, F. Puglisi, F. Cappelletti, R. Suriani*, M. Ravizza. Gastroenterologia Ospedale Valdese Torino Italy Ospedale di Rivoli Torino Italy*. Intestinal metaplasia in Barrett's patients is considered as a metaplastic premalignancy while fundic or junctional metaplasia are linked with little neoplastic risk.The reflux of both bile and acid is supposed to play a role in the genesis of intestinal metaplasia and displasia. Aim of this work was to relate the mixed reflux with gastric and intestinal metaplasia in Barrett's esophagus. 13 patients (9 with intestinal metaplasia, 3 with fundic and 1 with junctional metaplasia were investigated. They all underwent an endoscopy with biopsies, a manometry, a 24-hours gastroesophageal pH-metry combined with 24 hours esophageal bilimetry (Bilitec 2000) with 2 antimonium electrodes and 1 fiberoptic sensor. Abnormal esophageal exposure to both acid and bile, was the normal pattern in 8 patients with intestinal metaplasia, 1 had only acid reflux. The majority of biliary refluxes were found with pH lower than 4. Esophageal bile was generally found without any gastric alkaline shifts, only in 2 cases prolonged rises in gastric pH were associated to esophageal bile. The patients with fundic or junctional metaplasia showed mixed patological reflux in 1 cases and only acid reflux without bile in the remaining 3. Decreased LESP and weak esophageal waves were frequently found in all patients. In conclusions acid and duodenogastric reflux occur simultaneously in the majority of the episodes of reflux in Barrett's patients with intestinal metaplasia, while fundic metaplasia seems only to be acid related. PH-metry alone is ineffective to distinguish reflux compounds in the distal esophagus. Bilimetry with combined pH-metry appears useful to analyze the different compounds of refluxes in order to find among the Barrett's patients those at risk for whom surgical approach would be advisable. G0456 GASTRIC MYOELECTRICAL ACTIVITY AND GASTRIC EMPTYING IN PATIENTS WITH FUNCTIONAL DYSPEPSIA. E.Y. Eaker, Z.Y. Lin, I. Sarosiek, and R.W. McCallum, Department of Medicine, The University of Kansas Medical Center, Kansas City, Kansas Functional dyspepsia is a common clinical syndrome and its pathophysiology remains unclear. The aims of this study were to investigate gastric myoelectrical activity and gastric emptying (GE) and their relationship in patients with functional dyspepsia. Methods: The study was conducted in 15 healthy volunteers (6F, 9M, mean age: 42, range 21-56) and 8 patients (7F, 1M, mean age: 42, range 16-75) with functional dyspepsia. Gastric myoelectrical activity was recorded using cutaneous electrogastrography (EGG). The EGG was obtained for 30 minutes in the fasting state and for 120 minutes simultaneously with GE monitoring after an isotope-labeled solid test meal. The anterior and posterior scans of the stomach were taken using a technetium scanner immediately after eating, and then at 2 hours to determine the percentage of gastric retention. GE and EGGs were analyzed separately by different investigators. The dominant frequency of the EGG, the difference of EGG peak power after and before the meal (SP), and the percentage of normal 2-4 cycles/min (cpm) slow waves during each recording session were calculated and compared between the patients and healthy subjects. Results: The normal 2-4 cpm slow waves were present in over ninety percent of each recording period in healthy subjects. In contrast, the patients had a significantly lower mean percentage of 2-4 cpm slow waves in the fed state (mean -+ SD: 80.3 + 11.8% vs. 94.2 + 7.5% (healthy subjects), p < 0.05) but no significant difference in the fasting state (85.6-+ 15.8% vs. 92.5-+ 7.5%, p > 0.05). Compared to the EGG in the fasting state, a significant increase of the EGG dominant frequency was observed during the first postprandial hour in healthy subjects (2.88 -+0.07 cpm vs. 3.08 + 0.06 cpm, P < 0.04) but not in the patients (2.81-+0.16 cpm vs. 2.91 -+0.17 cpm, p>0.05). The mean postprandial EGG power increase in the patients was less than in the healthy subjects both during the first postprandial hour (2.1 -+4.0 dB vs. 3.0 -+4.1 dB) and during the second postprandial hour (1.2 -+ 3.3 dB vs. 1.5 -+ 2.5 dB). Of 8 patients, 5 (63%) had delayed GE (gastric retention at 2 hours > 50%). Four of these 5 patients (80%) had abnormal EGG (percentage of 2-4 cpm < 70% and/or ~P < 0) but the 3 with normal GE had normal EGG findings. Conclusion: 1) Fifty percent of patients with functional dyspepsia have abnormal postprandial gastric myoelectricai activity, including reduced normal 2-4 cpm waves, less increase in postprandial power and dominant frequency. 2) About 60% of patients with functional dyspepsia had abnormally slow GE and 80% of them had also abnormalities in gastric myoelectrical activity.
Esophageal, Gastric, and Duodenal Disorders Alll G0457 THE FREQUENCY OF INFECTIOUS ESOPHAGITIS IN PATIENTS WHO HAVE RECEIVED RADIATION THERAPY TO THE THORAX. Dayna S. Early, Rodnev A. Perez. Ellis Fischel Cancer Center and the University of Missouri Hospital and Clinics, Columbia, MO. Introduction: Patients receiving radiation therapy for thoracic malignancies often develop dysphagia and/or odynophagia during or after treatment. Patients with symptoms of esophagitis are often referred for endoscopy to rule out coexisting infection. We sought to determine how often esophagitis was actually due to esophageal infection, as opposed to radiation damage alone. Methods: Fifteen patients over a 2.5-year period were referred for a total of 21 upper endoscopies for the evaluation of dysphagia or odynophagia. All patients were receiving or had received radiation therapy for a thoracic malignancy (12 had lung cancer and 3 had esophageal cancer). Twelve of the fifteen patients had completed radiation therapy at the time of endoscopy, and had received a mean dose of 5382 cGy +/- 1112. The other three patients had received 5200, 5600, and 2600 cGy at the time of endoscopy. We retrospectively evaluated endoscopy, biopsy and cytology findings of these patients. Results: All patients had endoscopic findings of esophagitis at each exam. Five patients (33%) had a total of six documented infections (one patient had two separate infections) during 21 exams. Five of the six infections were caused by Candida species, and one of the infections was caused by herpes simplex virus. None of the patients with infectious esophagitis were neutropenic at the time the infection was diagnosed. Conclusion: Patients undergoing radiation therapy for thoracic malignancies may develop dysphagia and odynophagia during or after treatment. These symptoms may be due to radiation esophagitis, infectious esophagitis or both. In our series, one-third of patients developed infectious esophagitis post-radiation therapy. Diagnosing infectious esophagitis obviously has treatment implications, and endoscopy with biopsy should be considered in this setting. A normal neutrophil count does not preclude development of infectious esophagitis. • G0458 DAILY OR SEVERE HEARTBURN PREDICTS A FAVORABLE RESPONSE TO RANITIDINE 150 MG BID IN OTHERWISE HEALTHY ANTACID USERS. D. L. Earnest l, M. Robinson2, S. Rodriguez-Stanley 2, A. Ciociola 3. The University of Arizona Health Sciences Center I and The Oklahoma Foundation for Digestive Research at The University of Oklahoma Health Sciences Center 2, and GlaxoWellcome Inc. Tucson, AZ, Oklahoma City, OK and Research Triangle Park, NC. Background: Many otherwise healthy individuals with frequent moderate to severe episodic heartburn (HB) take antacids for relief. Purpose: To determine if persons with frequent or severe HB obtain more symptomatic relief from buffering of acid with pm antacid use or from acid-suppressing treatment with regular strength ranitidine (RAN). Methods: In subjects solely using antacids for relief of heartburn, this randomized double-blind two center trial involving a total of 155 individuals compared effervescent ranitidine 150 mg bid (RAN) to pm 750 mg calcium carbonate antacids (CC). The present analysis evaluated subgroups in terms of heartburn (HB) frequency and severity. Subjects with at least 3 months of HB relieved by antacids who experienced HB at least 4 out of 7 days per week were randomized to RAN plus placebo CC or to CC plus placebo RAN for 12 weeks. 59 subjects with mild to moderate HB received CC and 57 received RAN. 18 subjects had severe HB in both the CC and RAN treatment groups. Endoscopy at baseline revealed mostly normal findings or mild erosive esophagitis. Symptoms including HB frequency, severity and antacid use were recorded daily. Results: Symptom response to treatment stratified by HB frequency and severity are described below: Mean Number of Day am ght HB Episodes/Week Day Day Night Night Mild-Moderate Severe Mild-Moderate Severe CC 6.8 15.7 4.1 9.4 RAN 5.1 6.0* 2.6 2.3* *P < 0.05 vs. changes seen in the CC group All subjects reported a significantly lower number of HB episodes and less severe episodes during treatment. However, subjects with pre-study daily heartburn or severe heartburn that were treated with RAN reported the greatest improvement (P < 0.05) in symptoms. Conclusion: Subjects who self-medicate with antacids and who suffer with daily heartburn or who perceive their HB to be severe have a better symptom response to RAN compared to CC. These subjects should be educated that, while antacids are acceptable therapy with low risk, superior alternative treatments such as RAN are available. This study was supported by a grant from GlaxoWellcome, Inc.
Esophageal, Gastric, and Duodenal Disorders Alll G0457 THE FREQUENCY OF INFECTIOUS ESOPHAGITIS IN PATIENTS WHO HAVE RECEIVED RADIATION THERAPY TO THE THORAX. Dayna S. Early, Rodnev A. Perez. Ellis Fischel Cancer Center and the University of Missouri Hospital and Clinics, Columbia, MO. Introduction: Patients receiving radiation therapy for thoracic malignancies often develop dysphagia and/or odynophagia during or after treatment. Patients with symptoms of esophagitis are often referred for endoscopy to rule out coexisting infection. We sought to determine how often esophagitis was actually due to esophageal infection, as opposed to radiation damage alone. Methods: Fifteen patients over a 2.5-year period were referred for a total of 21 upper endoscopies for the evaluation of dysphagia or odynophagia. All patients were receiving or had received radiation therapy for a thoracic malignancy (12 had lung cancer and 3 had esophageal cancer). Twelve of the fifteen patients had completed radiation therapy at the time of endoscopy, and had received a mean dose of 5382 cGy +/- 1112. The other three patients had received 5200, 5600, and 2600 cGy at the time of endoscopy. We retrospectively evaluated endoscopy, biopsy and cytology findings of these patients. Results: All patients had endoscopic findings of esophagitis at each exam. Five patients (33%) had a total of six documented infections (one patient had two separate infections) during 21 exams. Five of the six infections were caused by Candida species, and one of the infections was caused by herpes simplex virus. None of the patients with infectious esophagitis were neutropenic at the time the infection was diagnosed. Conclusion: Patients undergoing radiation therapy for thoracic malignancies may develop dysphagia and odynophagia during or after treatment. These symptoms may be due to radiation esophagitis, infectious esophagitis or both. In our series, one-third of patients developed infectious esophagitis post-radiation therapy. Diagnosing infectious esophagitis obviously has treatment implications, and endoscopy with biopsy should be considered in this setting. A normal neutrophil count does not preclude development of infectious esophagitis. • G0458 DAILY OR SEVERE HEARTBURN PREDICTS A FAVORABLE RESPONSE TO RANITIDINE 150 MG BID IN OTHERWISE HEALTHY ANTACID USERS. D. L. Earnest l, M. Robinson2, S. Rodriguez-Stanley 2, A. Ciociola 3. The University of Arizona Health Sciences Center I and The Oklahoma Foundation for Digestive Research at The University of Oklahoma Health Sciences Center 2, and GlaxoWellcome Inc. Tucson, AZ, Oklahoma City, OK and Research Triangle Park, NC. Background: Many otherwise healthy individuals with frequent moderate to severe episodic heartburn (HB) take antacids for relief. Purpose: To determine if persons with frequent or severe HB obtain more symptomatic relief from buffering of acid with pm antacid use or from acid-suppressing treatment with regular strength ranitidine (RAN). Methods: In subjects solely using antacids for relief of heartburn, this randomized double-blind two center trial involving a total of 155 individuals compared effervescent ranitidine 150 mg bid (RAN) to pm 750 mg calcium carbonate antacids (CC). The present analysis evaluated subgroups in terms of heartburn (HB) frequency and severity. Subjects with at least 3 months of HB relieved by antacids who experienced HB at least 4 out of 7 days per week were randomized to RAN plus placebo CC or to CC plus placebo RAN for 12 weeks. 59 subjects with mild to moderate HB received CC and 57 received RAN. 18 subjects had severe HB in both the CC and RAN treatment groups. Endoscopy at baseline revealed mostly normal findings or mild erosive esophagitis. Symptoms including HB frequency, severity and antacid use were recorded daily. Results: Symptom response to treatment stratified by HB frequency and severity are described below: Mean Number of Day am ght HB Episodes/Week Day Day Night Night Mild-Moderate Severe Mild-Moderate Severe CC 6.8 15.7 4.1 9.4 RAN 5.1 6.0* 2.6 2.3* *P < 0.05 vs. changes seen in the CC group All subjects reported a significantly lower number of HB episodes and less severe episodes during treatment. However, subjects with pre-study daily heartburn or severe heartburn that were treated with RAN reported the greatest improvement (P < 0.05) in symptoms. Conclusion: Subjects who self-medicate with antacids and who suffer with daily heartburn or who perceive their HB to be severe have a better symptom response to RAN compared to CC. These subjects should be educated that, while antacids are acceptable therapy with low risk, superior alternative treatments such as RAN are available. This study was supported by a grant from GlaxoWellcome, Inc.